Suboxone and Buprenorphine in the Treatment of Opiate Addiction

Currently, there is an epidemic of opiate addiction in the USA that is primarily being fueled by the overly liberal use of narcotics in the treatment of non-malignant pain. Deaths due to opiate overdose doubled between 2001 and 2005 (see the accompanying post on this page entitled: “The Epidemic of Opiate Addiction due to Prescription Drugs”). Opiate addiction is notoriously difficult to treat owing to the highly addictive nature of opiates. Opiates (or their synthetic cousins, Opioids) are one of only two drugs that stimulate release of dopamine at both pleasure centers within the brain. This fact, combined with the extremely uncomfortable opiate withdrawal syndrome, compel the user (on a neurobiological basis) to persist in the use of narcotics–even when they no longer get high from using them. On top of this, non-prescription use of opioids is illegal (unlike alcohol which is easily obtainable) and the stigma surrounding narcotic addiction is much worse than that of alcoholism. Obviously, there are some good reasons for the stigma since opiate addicts will: manipulate doctors, forge prescriptions, deal drugs, commit murders, steal, or prostitute themselves to obtain their drugs. Once the addiction takes hold, the addict becomes a tornado ripping through the lives of family, friends, and society. To make things worse, the treatment of narcotic addiction is extremely controversial. Many people are opposed to the use of Methadone or Suboxone because they see this as the substitution of one addiction for another. Also, many people in the sober community (i.e., those recovering in 12 step programs) are opposed to the use of Suboxone because they do not consider that to be consistent with sobriety.

How can we make sense of this difficult problem and what are the facts surrounding this difficult issue? The medical approach to disease is to consider the biological, psychological, and social impact of the disease in question. Let’s begin with the biology. The most addictive drug on the planet is nicotine (with 33% of smokers becoming addicted) and a close second is opiates at 27%. The relapse rate for opiate addicts without treatment with Suboxone or Methadone is 85%. The relapse rate with treatment with Suboxone or Methadone drops to 50%. Suboxone is essentially “Son of Methadone”–it does the same thing that Methadone does except that its pharmacologic properties are different in a manner that enhances its safety. The purpose of these “substitutive therapies” is three-fold: 1) Eliminate drug craving; 2) Eliminate “Dope Sickness” (i.e. the uncomfortable opiate withdrawal syndrome); and 3) If the patient is on the right dose and they do short-acting opiates—they won’t get high.

The problem with the strict biological approach to opiate addiction is that it does nothing to address the psychological aspects of the illness. The disease of the addict is within the mind. Mere substitution therapy, without addressing the thinking and behavior of an addict, is not the answer. At this point in the discussion the reader needs to be aware of the difference in dependence versus addiction. Dependence means that the patient is dependent on Methadone or Suboxone such that, if he does not have the medication, he will go into withdrawal. Addiction is both dependence and the behaviors associated with active addiction: lying, manipulating, drug seeking, theft, prostitution, etc. The long-term data obtained from the Methadone experience shows that 50 % of those on Methadone maintenance are still active in their disease of addiction. They are just using Methadone or Suboxone as a backstop until they can get their drug of choice. In the case of Methadone (a full agonist at the mu narcotic receptor in the brain), an active drug addict will walk into the Methadone clinic, get his dose of Methadone, and upon leaving the clinic will supplement it with alcohol, Xanax, Cocaine, or other drugs in order to “get a boost.” The other 50% of those treated with Methadone are evenly divided into two groups (each comprising 25% of the total): 1) this group will eventually get completely off of Methadone and go on to an otherwise normal life; 2) this group will be dependent on Methadone indefinitely and will not abuse anything stronger than nicotine or caffeine. Both groups will go on to work, have families, pay taxes, and do everything else that otherwise normal people would do. Meanwhile, the unrecovered 50% will go on to insanity, incarceration, or death. The key to healing in the 50% who are no longer displaying “addict behavior” is a complete psychic change. For discussion of this aspect of recovery, please see the article on this page entitled “Addiction Medicine: The Intersection of Science and Spirituality.”

Finally, we come to the social aspects of the disease. By now everyone reading this is well aware of the stigma and judgment surrounding the addict or alcoholic population. Why is it that a Methadone or Suboxone provider would continue to prescribe to someone that is still an active addict? The answer is that some do and some don’t. It is usually based on a pre-existing policy agreement between the provider and the patient, federal regulations, and a case-by-case assessment. From a social perspective, treatment with Methadone or Suboxone is consistent with a “harm reduction” approach to the management of disease. Harm reduction is essentially reducing the harm to society caused by the addicts’ use of Heroin or other illegal narcotics. Every time a clinician in a Methadone clinic gives a Heroin addict Methadone he is taking a thief, a drug dealer, or a prostitute off of the streets. This reduces crime and the spread of diseases such as HIV, Hepatitis C, and other STD’s. Likewise, furnishing sterile needles and condoms is consistent with efforts at harm reduction. The reasoning is that since you are powerless over other people’s addictions (or sexual behavior) the best way to protect society as a whole is to use half measures which reduces morbidity and mortality. This is very common in the medical setting. For instance, the disease of type 2 diabetes is caused by obesity. Getting people to lose weight is extremely difficult, but providing them with pills that reduce their appetite, decrease their blood sugar, and control their cholesterol and blood pressure is relatively easy to do. Are these ideal solutions? No. We don’t live in an ideal world. In an ideal world, all addicts or alcoholics would get clean and sober through 12 step programs and all type 2 diabetics would lose the weight and get fit. This doesn’t happen. The reality is that half of the addicts out there will eventually wake-up and begin to change their mind set (usually through a spiritual awakening or psychic change) and the other half will continue doing the same thing over and over and expecting different results. Insanity=doing the same thing over and over and expecting different results.


Dual Diagnosis: Addiction + Anxiety or Depression or Bipolar or ADHD, etc.

The four correlates of long term sobriety are: constitutionally capable of being honest with yourself; goes to 12 step meetings; does a thorough 5th step followed by a 9th step; and, if you have a concurrent psychiatric disorder you take non-addictive medication to manage it. The focus of this article is on the 4th correlate of long-term sobriety: the diagnosis and treatment of concurrent psychiatric disorders.

Large studies of the alcoholic/addict population have confirmed that 37% of alcoholics and 53% of opiate addicts have concurrent and often undiagnosed psychiatric disorders. Relapse is incredibly common in those patients who fall through the cracks and fail to have these disorders treated. I have personally seen countless patients who have worked impressive 12 step programs only to relapse because they failed to address these illnesses.

Why does this occur? The answer lies in our cultural attitudes toward these illnesses. Lets face it, we live in the culture of John Wayne–where everyone is rough, tough, individualistic, and pulls themselves up by their bootstraps. In this culture to have alcoholism, addiction, anxiety or depression is not socially acceptable. Having these illnesses means that you have: a weakness of character, an inability to deal with life, a lack of willpower, a case of chronic wimphood, or–worse yet–a moral failing. This is complete nonsense.

These illnesses have a genetic and neurobiological basis. In the case of alcoholism, we know that 60 % of alcoholics are genetic alcoholics–the other 40 % drink themselves into the illness (please see the accompanying article on this page entitled: “The Disease Concept of Alcoholism and Drug Addiction). There are also strong genetic and biochemical determinants of depression, anxiety, bipolar, and ADHD. These are not weaknesses of character or a moral failing–they are neurochemical imbalances in the brain that can be triggered by viral infections, general anesthesia, or stressful life circumstances. In other words, they are medical illnesses. There is a target organ that is affected–in this case the brain–we give you the medicine and the rehab and, if you take it, you get better. What’s the catch? You have to take the medicine and do the work!!!

Why is compliance with medication and treatment such a big deal? Well, as it turns out, this is a really common problem in any field of medicine. No one likes to take medicine and most people have trouble taking medications if they have to take it more than once a day. However, in the field of addiction medicine there is an additional impediment to compliance and that is known as “denial” or “ego defenses.” This is a problem because the treatment is focused on the brain, also known as your survival tool, also known as “the onboard computer.” Anytime anybody is going to do anything with the onboard computer–look out–the so-called ego defenses leap into action to rescue the unwitting victim!!!

What am I talking about and what does this look like in real life? Here’s a great example right out of my own experience. I was working as an attending physician at an inpatient drug rehab when I met and admitted a 24 year-old man who had just spent 10 days in the ICU after overdosing on a liter of Vodka a day plus “speedballs” (i.e. heroin and cocaine mixed together and injected iv–this is what killed John Belushi). I was admitting him to rehab and at the end of the interview I told him that I thought that he had signs and symptoms consistent with depression and that he could benefit from Prozac. His response was: “Oh Nooo Dude, I don’t want any drugs!!!” Here’s a guy who would shoot-up God knows what that he could get off the street and then chase it with Vodka who’s telling me that he’s scared to take Prozac!!! This medication is effective, extensively researched, FDA approved, pharmacologically pure, cheap (because its generic and off-patent), and it is not a drug of abuse. What’s wrong with this picture!!! I actually laughed out loud at the absurdity of his response.

Unfortunately, the aforementioned scenario is not unusual or atypical. It reflects several mistaken notions that are harbored by the lay public, the media, and those who suffer from “contempt prior to examination.” The prescription drugs that get patients into trouble are the benzodiazepines (a.k.a. alcohol in pill form like Xanax, Klonopin, Ativan, Valium, Librium, etc.) and narcotics (e.g. Vicodin, Percocet, Morphine, Heroin, etc.). Anti-depressants, mood stabilizers, and anti-psychotics are not drugs of abuse. You don’t get high from them. In fact, in the case of anti-depressants, they are not immediately effective. You have to take them consistently and at therapeutic doses for 2 to 6 weeks before you get maximum therapeutic benefit. Once the anti-depressant kicks in the patient will notice the following: sleep improves, energy level rises, appetite normalizes, sex drive returns, and their short-term memory and concentration improves. All this for $4 a month at Wal-Mart!!!

As it turns out, the young man in the example above fell prey to “black and white thinking”, faulty assessment of risk versus benefit, and “contempt prior to investigation.” Since booze and drugs landed him in the ICU, any drug that might mess with the onboard computer must be bad. Then he relied on the media and the internet to tell him that if he took Prozac he would automatically commit suicide. This was a headline some years back, but when an 8 year retrospective study was conducted it showed that it wasn’t the Prozac that caused suicides–it was the disease of depression that it was designed to treat. Unfortunately, that’s a headline that doesn’t sell newspapers and therefore is not “news worthy”. Finally, he thought that his addiction and depression were conditions that would yield to his willpower–in other words, he would be able to think himself into sobriety and wellness. He did not understand the neurobiologic basis of these disease states. His faulty reasoning in this case is the equivalent of a patient with a bad case of Montezuma’s revenge deciding that he will use willpower to control his diarrhea. It will work for a little while, but in the end, Montezuma’s revenge will have its way with him and he will have diarrhea, vomiting, abdominal cramping, etc.

The point is that these so-called psychiatric conditions are really medical conditions. There is a target organ that is affected and the idea is to give the patient the treatment to correct the neurochemical imbalance. Does this mean that pills are the answers to all your ills? Of course not. Relying solely on “better living through chemistry” will not succeed. The patient needs to learn how to live life on life’s terms. This means doing the very real work of rehab. It’s just like when you get a hip replacement. Doing the surgery is only a small part of the recovery. The patient must have extensive physical therapy in order to get back to normal. It’s no different in psychiatry or addiction—the same rules apply.


Addiction Medicine: The Intersection of Spirituality and Science

“Any problem which can be solved with money is not really a problem.” – Anonymous

No amount of money and no amount of “medicine” will heal an addiction. The fundamental healing that occurs in the setting of addiction comes about as the result of a spiritual awakening. For some reason, as yet unknown by science, a spiritual awakening displaces the compulsion to drink or use drugs. Science, with all its power and knowledge, may assist the process but it cannot supplant it. This simple fact has been known for the past 74 years and the process for achieving the spiritual awakening was codified in the first 164 pages of the Big Book of Alcoholics Anonymous some 70 years ago in 1939. Not one word of the first 164 pages of that book has changed since it was written. It is classic knowledge and it contains a “spiritual technology” which can enable anyone, regardless of their beliefs—or the lack thereof, to achieve a fundamental psychic change, which will ensure sobriety so long as that person maintains a fit spiritual condition.

Unfortunately for some, “spirituality” is inextricably bound to “religion” and many of the people who enter recovery have been traumatized by their early “religious” training. In effect, they have been “de-churched” and the mere mention of spiritual matters evokes strong feelings of resistance, or even revulsion. “God” or a “Higher Power” is an anathema to these people and it is something that they reject out of hand. In the course of growing up, our first contact with a “higher power” is often in the guise of our parents. Most addicts and alcoholics come from families in which the disease was active and emotional, physical, or even sexual traumas have occurred. Given this possible history of family trauma, it would make sense that these people would reject a “higher power” concept. Even when this type of trauma has not occurred, the afflicted may reject the idea of a higher power based upon their intellectual constructs or their life experience to date.

Alternatively, some people have a strong faith in the God of their religion, but this faith does not keep them sober. What this amounts to is “faith without works.” The spiritual technology set forth in the 12 steps of Alcoholics Anonymous is hard work. Getting sober is hard work. Staying sober also requires ongoing work, however, it is much easier to stay sober than to get sober. Getting sober is like pushing a broken-down car on a flat road—it takes a lot of energy to get the car moving, but once its moving it takes less energy to keep it rolling. In any event, the key ingredient to sobriety involves a spiritual awakening which occurs as a result of “working the steps.”

The “science” involved in addiction medicine has to do with the use of various tools in order to facilitate a spiritual awakening. These tools include: an introduction to 12 step concepts and philosophy, individual and small group psychotherapy, and the use of medications to manage cravings and concurrent psychiatric disorders (aka. Dual Diagnosis). Science does not have a “magic bullet” for the disease of addiction. There is no drug, vitamin, or technical procedure that can ensure sobriety. However, treatment of concurrent psychiatric disorders has been shown to improve the duration and quality of sobriety in affected patients.

The purpose of this website is to offer encouragement, information, and general knowledge on the topic of addiction and alcoholism. The author believes that “healing and sobriety are possible for anyone” provided that the individual is willing to do some simple (but not easy) work.


Medications to Control Cravings

During the early part of recovery, from alcoholism or addiction, the patient may experience extreme cravings, which can lead to recurrent drug or alcohol abuse. A variety of medications exist which, when used appropriately in early recovery, can decrease the amount of craving that an addict will experience. The purpose of this article is to acquaint the reader with the various types of medications and their uses during early recovery. This article serves only as a brief introduction and is not an exhaustive discussion of the various medications, their side effects, or their other uses in clinical practice.

In keeping with a “first things first” approach, it will be necessary to discuss the limits of medication in the treatment of addictive disorders. Typically, addicts and alcoholics enter treatment with a philosophy of “better living through chemistry”. Unfortunately, modern medicine has done a lot to foster this maladaptive approach. It seems that we in the medical profession are always looking for that magic bullet, usually in the form of a medication or technical procedure, which will result in instant healing and cure of our patients. Clearly, there is some merit in this approach as seen in the numerous advances that have been made in the science and technology of medicine. However, like any other model, it has its limitations and these must be respected especially in the setting of the disease of addiction. The most important point to get across to the reader is that addiction is multifactorial; it encompasses biological, psychological, social, emotional, familial, and spiritual aspects of a patient’s life. The use of medication, while important for treating some aspects of the disease, is by no means a panacea. In order for this disease to be effectively treated it must be approached on all these different levels.

In early recovery some medications have been demonstrated to have some salutary effects with respect to the control of craving. In the setting of alcoholism, there are two medications for the control of craving, and one medication that acts as negative reinforcement with respect to the consumption of alcohol. The medicines that are effective for craving are naltrexone and acamprosate. Naltrexone is an opiate antagonist within the central nervous system, which was observed to decrease alcohol consumption. It comes in oral and injectable formulations. The injectable formulation, while very expensive, is the preferred treatment because it results in greater compliance (i.e. patients are able to take it reliably) than the oral formulation. Acamprosate targets the brains glutamate system and it is an oral formulation taken three times daily. Disulfiram, also known as Antabuse, is the oldest medication- based treatment for alcoholism and it acts as a negative reinforcement to drinking. If a patient taking Antabuse begins to drink alcohol they will become extremely ill to the point of requiring a visit to the emergency room. The rates of compliance with Antabuse are low, but it is frequently used in early sobriety when it is given by a concerned relative or by medical personnel who can supervise its consumption.

In the setting of opiate addiction, the two drugs that are effective for the control of craving are methadone and Suboxone. Both of these medicines can be used during detoxification and can also be used for induction of opioid maintenance. Methadone is a narcotic with a long half-life, which has a lower abuse potential than other shorter acting narcotics. The advantage of methadone is that it is cheaper than Suboxone, but its principal disadvantage is that it requires attendance at a methadone clinic on a frequent basis. Suboxone does not carry the same stigma that methadone carries and it can be prescribed in the outpatient setting by any physician with a special license to do so. Another medication that can be helpful in the setting of opiate addiction is clonidine. This is actually a blood pressure medication, which has been found to ease the symptoms associated with detoxification.

The medications which have been effective in decreasing craving in the setting of stimulant or cocaine abuse have included the following: Antabuse, Provigil (a non-amphetamine stimulant), propranolol, baclofen, and Topamax. Drug manufacturers are also pursuing the development of a cocaine vaccine, which would produce cocaine-specific antibodies that would bind to cocaine in the circulation and prevent it from crossing the blood brain barrier.

For those patients interested in smoking cessation, a variety of medications can help with the control of craving including: nicotine supplements in the form of gum or patches, bupropion (an atypical antidepressant), and Chantix. Recently however, Chantix has been found to have unfavorable side effects including: depression, anxiety, suicidal thoughts or behaviors, and even psychotic symptoms. The FDA has recently issued a black box warning for Chantix highlighting the aforementioned adverse effects. In any event, the medications used to decrease craving in the setting of nicotine addiction are only effective in terms of smoking cessation if they are combined with a behavioral plan targeted at abstinence.


The Epidemic of Opiate Addiction Due to Prescription Drugs

A recent article in the Mayo Clinic Proceedings highlighted the severity of opiate addiction due to prescription drug abuse. According to the article in the July 2009 edition: “nonmedical use of prescription opioids has increased exponentially since the early 1990s. Not surprisingly, the expanded use of prescription opioids for all reasons, legitimate and illicit, has correlated with the steady increase in opioid related deaths nationwide.” The article noted that “methadone related adverse events increased 1800% between 1997 and 2004; fatalities increased 390% from 1999 to 2004(the most recent national data available), and methadone was the drug with the greatest increase in fatalities; methadone also is the sixth most frequently suspected drug in death and serious nonfatal outcomes. . . Half of methadone deaths are pain patients who are being mismanaged by physicians who lack sufficient knowledge or skills to use methadone in the treatment of pain.” The number of deaths due to prescription opioids in 2001 was 3,994 and this more than doubled in 2005 to 8,541.

What accounts for this drastic increase in deaths due to prescription opiates? In the opinion of this author, the current epidemic of prescription opiate addiction and deaths have come about as a result of the “pain movement”. In the late 80s and early 90s, numerous studies within the medical literature indicated that physicians were under-treating pain in the setting of advanced cancer and other terminal conditions. The “pain movement” originated as a valid response to the dilemma of poor pain control in the setting of malignancy and other potentially terminal conditions. Unfortunately, unbridled enthusiasm on the part of “pain doctors” soon led to the use of narcotics for the management of chronic forms of nonmalignant pain. While the use of narcotics in some of these conditions is certainly justified, the difficulty that arose had to do with the dissemination of this information to overburdened primary care doctors who would now be expected to become pain experts and to manage their patients with the same skill and oversight that was being promulgated by academicians.

Another factor which contributed to the problem had to do with the patient population being managed by the academicians. The patients managed by the academicians were highly selected and thoroughly screened for a pre-existing history of substance abuse or other risk factors likely to predispose them to the adverse outcomes associated with narcotic addiction. Obviously, this is not the population that a primary care doctor would be seeing. Also, the amount of time dedicated to the evaluation of these patients within the academic setting was likely much greater than the amount of time spent by the harried primary care doctor (or even the community-based “pain doctor”). Given this set of circumstances it is no wonder that we have an epidemic of opiate addiction related to the overuse of narcotics.

Of course, some unscrupulous physicians have also seen the profit potential which exists for servicing addictions and, at this writing, a bill is currently pending in the Texas Legislature to outlaw so-called “pill mills” — — these are clinics which are infamous for their reputation of prescribing narcotics at the drop of a hat.


Dangerous Withdrawal and Overdose Syndromes: Alcohol, Benzodiazepines, Barbiturates, and Opiates

The purpose of this article is to acquaint the reader with some dangerous withdrawal and overdose syndromes that can occur in the setting of alcohol and substance abuse. The drugs that will be discussed in this article are central nervous system depressants, which in an overdose situation have the capacity to kill the patient by impairing their respirations. An overdose of any of these substances constitutes a medical emergency and care should be sought via the emergency room. The withdrawal syndromes that can accompany these drugs can range from uncomfortable symptoms to lethal complications. Generally speaking, the withdrawal syndrome associated with a drug is the opposite of its clinical effect. In other words, the withdrawal syndrome associated with central nervous system depressants is characterized by: anxiety, insomnia, agitation, tremors (or “the shakes”), the potential for seizures, and a variety of other symptoms related to the hyperactivity of the central nervous system in the absence of its drug of “no choice” (i.e. a drug that once you start using it, you can’t quit without outside help). Some of the drugs that we will discuss will have symptoms and signs in common; however, there are some important differences, which will be highlighted in the following paragraphs.

Alcohol is the most commonly used and abused substance in this culture. The symptoms of intoxication and overdose can vary from person to person depending upon their tolerance for the drug, their body weight, their sex (women are more susceptible than men), and whether or not they are using any concurrent drugs. The level of alcohol in the blood stream is expressed in milligram percent (i.e. mg %). In Texas, a blood alcohol level of 80 mg% meets the criteria for intoxication and can result in a DWI. A non-tolerant drinker with a blood alcohol level of 150 mg% (approximately 7-8 drinks) will experience gross motor incoordination, confusion, and disorientation. An alcohol level of 350-400 mg% is usually lethal in a non-tolerant drinker and can lead to respiratory or circulatory collapse. Combining alcohol with other drugs heightens the risk of a bad outcome.

Withdrawal from alcohol can range from minor symptoms of a hangover to potentially lethal seizures in the setting of delirium tremens. The severity of the withdrawal is usually proportional to the amount of alcohol that has been consumed on a daily basis. However, there is a lot of individual variation and some individuals will have serious symptoms with relatively low levels of drinking. Any drinker who manifests “the shakes” or any patient consuming more than twelve drinks in a 24-hour period is at high risk for alcohol withdrawal and must be closely observed in a medical detox facility. The physical stress and strain of withdrawal can worsen underlying medical conditions and necessitates a medical evaluation. Remember, untreated alcohol withdrawal can kill!! If there is any doubt, contact a treatment center for evaluation, or, failing that, go to the emergency room. Outpatient detoxification is sometimes attempted in mild cases; however, this is tricky owing to the need to use benzodiazepines (i.e. Valium-like drugs, e.g. Ativan, Librium, Xanax, etc.) for the purpose of detoxification. If those benzodiazepines are combined with alcohol, a lethal synergistic reaction can occur. For this reason, this author does not advocate outpatient detox. If, however, it is going to be tried then it makes sense to have the benzodiazepines administered by a sober person who can be relied upon to give them as directed and to call the doctor if there are questions or problems.

Benzodiazepines and barbiturates (e.g. Seconal) are cross-tolerant with alcohol (in other words, taking one of these pills is like taking a drink) and the withdrawal syndrome that they can induce is similar in intensity and severity to that of alcohol. Likewise, an overdose of these medications can cause respiratory depression and death (although this is more likely with barbiturates than with benzodiazepines). The medical management of overdose and withdrawal from these substances is very similar to that of alcohol.

Interestingly, opiate withdrawal is not dangerous; however, any opiate addict will assure you that while it may not kill you, it will certainly make you miserable. From the medical standpoint, the severity of opiate withdrawal is similar to that of a bad case of the “flu”. The patient will have muscle aches, “goose flesh” (hence the origin of the term “cold turkey”), runny nose, severe anxiety, insomnia, and intense craving for their drug of “no choice.” This author has spoken with recovering heroin addicts regarding the severity of opiate withdrawal. One of those recovering addicts described the level of anxiety as follows: “Doc, it’s as if you were in a 747 flying over the middle of the Atlantic Ocean and the pilot came on the intercom and told you the plane was going to crash.” Indeed, early on, this author attempted to detox a 25-year-old woman using only supportive measures, rather than “medication assisted treatment” (i.e. Methadone or Suboxone). This woman experienced so much craving and anxiety that she climbed a 14-foot high iron rail fence with spikes at the top; she then went out and scored and then promptly returned to the facility after dosing herself with Heroin. Obviously, this patient was serious about wanting to recover, otherwise she wouldn’t have returned to the facility. However, the discomfort she felt from the withdrawal process spurred her into action to satisfy her craving. Since that time, this author has been a proponent of “medication assisted treatment”.

The purpose of this article has been to alert the reader to the potential dangers associated with the various overdose and withdrawal syndromes that can occur in the setting of alcohol and drug abuse. In managing a withdrawal syndrome, this author endeavors to make the process as comfortable as possible; however, it is not possible to relieve all of the suffering attendant to the various withdrawal syndromes. By the same token, detoxification is not “rehabilitation”; it is only the first step in an ongoing process of recovery.


The Disease Concept of Alcoholism and Drug Addiction

During the course of my career as a general internist, I have come to believe that 80% of illnesses are lifestyle induced and 20% are the result of bad genes, bad luck, or a bad infection. My job is to ask myself whether or not the patient sitting in front of me is an “80 percenter” or a “20 percenter”. If the patient is a 20 percenter, then the diagnostic workup will be more involved than the workup of someone with a common illness. It is my belief that 80% of those individuals with common illnesses are suffering from an addiction. I define an addiction as a pathological relationship to a mood altering substance, behavior, emotion, or relationship that results in life damaging consequences. Using this very broad definition of addiction, I can define my obese, type 2 diabetics as food addicts. These diabetic patients use food to mood-alter an uncomfortable emotional state. Indeed, food is the cheapest drug available in American society. The end result of food addiction is early death due to heart attack, heart failure, or end-stage kidney disease requiring dialysis. However, if I were to label my diabetic patients as “food addicts” they would look at me as if I were crazy. These patients do not view themselves as addicts simply because “no one ever got arrested for driving while fat.”

In other words, in order to be considered an addict a person must have violated some social norm or legal standard. Typically, addicts and alcoholics are viewed as weak willed or morally bankrupt individuals who have lost the power of choice when it comes to the use of drugs or alcohol. This mistaken notion is a byproduct of American culture. We live in the society of John Wayne; where everyone is rough, tough, and individualistic and pulls themselves up by their bootstraps. If you are an addict or an alcoholic, you have a weakness of character, an inability to deal with life, or a case of chronic “wimphood”. Given this set of circumstances, it is no wonder that denial runs rampant in the setting of these diseases. Who in their right mind, would ever admit to being an addict or an alcoholic given the social stigma that surrounds the disease. This unfortunate set of circumstances results in untold suffering in millions of people. Unfortunately, these persistent myths shame the afflicted and prevent them from getting the treatment that they need.

The truth of the matter, however, is that addiction and alcoholism are brain diseases. The brain, for the purpose of this discussion, can be divided into three major areas: the pons and medulla or “reptilian brain”; the mesolimbic system also known as the “emotional brain” or the “rat brain”; and the cortical brain or the “big brain”. The reptilian brain tells your heart how often to beat and how often you should breathe. In other words, it coordinates automatic functions within your body. The mesolimbic system, or rat brain, sits above the primitive reptilian brain– and this is where the disease of addiction resides. The cortical brain represents what we think of as characteristic of an individual human being. It is the repository for higher thinking, personality, willpower, and the capacity to judge, plan, moralize, or philosophize. The hierarchical organization of the brain is such that the reptilian brain will trump the emotional brain, which will trump the cortical brain.

What then, is the purpose of the emotional brain? From the evolutionary standpoint, the emotional brain exists for a very good reason; there are certain activities in life that are essential to survival, these include: food, sex, exercise, and drinking water when you’re thirsty. When you perform these acts, so-called pleasure chemicals are released in the emotional brain which tells you at an irrational, nonverbal, emotional level to: “keep doing this– it’s essential to your survival”. Drugs of abuse (such as alcohol, heroin, cocaine, methamphetamine, etc.) directly and reliably stimulate the production of these pleasure chemicals within the emotional brain. Each time the addict or alcoholic takes a “hit” or a “drink” they are directly stimulating the release of chemicals that tell them “keep doing this– it’s essential to your survival”. Notice that the term is “essential”, not optional. In effect, the addict’s brain is hijacked by their drug of “no choice”. Once they begin to use their drug of “no choice” they trip the switch on a self-reinforcing circuit, which perpetuates a deadly obsession and compulsion.

All of this occurs in a very primitive area of the brain. The deeper within the brain that the lesion exists, the more difficult it is to eradicate. The prevailing or stereotypical view of this disease suggests that the disease is due to a lack of willpower. Of course, this is not true. Willpower is a function of the cortical brain, which sits above the emotional brain. Willpower is ineffective in changing lower brain functions. The following example is instructive with respect to the limitations of willpower; when my youngest son was eight years old he went out on Halloween night for trick-or-treat. The next day he had a bag filled with candy. He was overindulging in the candy and I took the bag away from him, at which point he threatened to hold his breath until he died unless I gave him the candy. Of course, I said go ahead and try. By sheer force of will he attempted to hold his breath until he would die — — needless to say, this didn’t work. It didn’t work because his lower brain, i.e. the reptilian brain, overrode his desire to hold his breath. In the case of the alcoholic or drug addict, their attempts at controlling their disease through willpower are doomed to failure because they are trying to override a lower brain function by depending upon a higher brain function.

So does this mean that the addict is doomed? No, of course not. It means that he has a disease that can be arrested, but not cured. How then, is the disease arrested? First of all, the degree and severity of the disease must be assessed with respect to the need for inpatient detoxification or concurrent medical or psychiatric care. Once the patient is stabilized, the real work of recovery begins. To date, the most effective means of arresting the disease of addiction or alcoholism comes about as a result of a spiritual awakening. For some reason, as yet unknown by modern medical science, a spiritual awakening has the capacity to displace the compulsion to use drugs or drink. Of course, I am a medical doctor — — I don’t dispense spiritual awakenings. The most reliable means for attaining a spiritual awakening in the setting of alcoholism or addiction comes about as a result of working the 12 steps. The 12 steps is a spiritual technology that has the capacity to free the individual from the deadly obsession and compulsion with which he is afflicted.

The problem with the 12 steps is that many people confuse it with religion. 12 step programs focus on spirituality, not religion. In effect, spirituality represents the progressive death of self-centeredness combined with the growing awareness that the purpose of life transcends the mere gratification of instinctual drives. A key component of spirituality is the discovery of, and dependence upon, a power greater than oneself. However, the definition of that higher power is left up to each individual. The road to recovery is broad and inclusive; it is also simple, but not easy. The purpose of my practice is to use my skills as a medical doctor to facilitate the growth and eventual recovery of my patients. It is my belief that anyone can recover if they are willing to follow a few simple suggestions and to work at their own healing.


Addiction, The Disease of the Latter 20th Century

The purpose of this essay is to acquaint the reader with the “elephant in the living room”, i.e., the disease of addiction. Addiction, or its secondary manifestations, represents the most common cause of suffering and death in this country today. This idea, however, is a new one and is not widely embraced by the medical community as a whole or by our current society. The failure to identify this mechanism of disease as a primary cause of death and disability relates to how the disease is perceived at the societal level. Most often, people think of addiction as a destructive habit related to the excess use of drugs or alcohol, which results in the violation of social norms or legal standards. The negative societal stereotypes associated with addiction ascribe its cause to: a weakness of character; a moral failing; or an inability to deal with life. Given this set of circumstances, the application of the label “addict” is associated with considerable stigma. To some degree, the presence of denial is understandable given the negative social stigma.

The key to understanding addiction as a primary pathophysiologic mechanism lies in its definition and its relationship to the physiology of brain function. Webster’s Unabridged Dictionary (2001) defines addiction as: “the state of being enslaved to a habit or practice or to something that is psychologically or physically habit-forming, as narcotics, to such an extent that its cessation causes severe trauma.” This is a very good definition and a good starting point. From the standpoint of a disease model, this author defines addiction as: “a pathologic relationship to a mood-altering substance, behavior, emotion, or relationship that results in life damaging consequences.” Using this very broad definition, this author can define his obese, type 2 diabetics as food addicts. These patients use food to mood-alter uncomfortable emotional states. However, the recognition of the primacy of addiction as a cause of obesity is not reflected in the medical literature. Typically, medical reviews of obesity ascribe its cause to: a sedentary lifestyle, genetics, rare endocrine diseases, or a simple excess of caloric intake related to caloric expenditure.

Interestingly, however, the current pharmacologic research in obesity revolves around brain function and the neurotransmitters associated with the endocannabinoid system. Yes, cannabinoids, i.e. receptors in the brain that are stimulated by marijuana. According to the Journal of the American Dietetic Association (2008;108:823-831): “Weight gain, particularly abdominal fat mass gain, along with consumption of a high-fat, high calorie diet are postulated to overstimulate the endocannabinoid system, initiating deregulation contributing to the pathophysiology of body weight regulation.” This statement implies that central nervous system regulation of body weight is a key factor in obesity. But how does the central nervous system regulation of weight relate to the disease of addiction?

From a biological perspective, the disease of addiction is a central nervous system disease. The brain, for the purposes of this discussion, can be divided into three separate areas. The “reptilian brain” consists of the pons and the medulla; this is a very primitive area of the brain that regulates automatic functions such as how often your heart beats and how often you breathe. Above the reptilian brain, is the “emotional brain”; this is the area of the brain that is involved in the disease of addiction. Above the emotional brain and is the cortical brain. The cortical brain is what we think of as representative of the attributes of a human being. The cortical brain is the repository of the ability to plan, to think, to analyze, to philosophize, to moralize, and to exert one’s “willpower”. A general law of brain function is that lower areas of the brain have the capacity to trump higher areas of the brain.

The disease of addiction resides within the emotional brain. From an evolutionary standpoint, the emotional brain exists for a very good reason; the emotional brain contains the pleasure center and stimulation of the pleasure center reinforces a human being to perform acts that are characterized as “essential” to survival. There are certain activities in life that are essential to survival; those activities are: food, sex, exercise, and drinking water when you’re thirsty. All of these natural activities result in the stimulation of the pleasure center, which conveys to the human being (at an irrational, emotional, nonverbal level) that the current activity is “essential” to survival. It turns out that drugs of abuse directly and reliably stimulate these pleasure centers resulting in the feeling that the continued intake of drugs or alcohol is “essential” to survival. In effect, drugs of abuse, of which food may be considered one, hijack the emotional brain and override the impulses of willpower exerted by the cortical brain. This is the essence of addiction at the neurochemical level.

Currently, our country is in the midst of an epidemic of obesity. The medical consequences of obesity are numerous, dangerous, and life limiting. However, this is not the only manifestation of addiction that results in increased suffering and death within the population. Cigarette smoking, a manifestation of addiction to nicotine, is the cause of the number one cancer in American society, i.e., lung cancer. Alcohol, a more traditionally recognized substance of abuse, results in significant morbidity and mortality as noted in the following: 15% of men and 10% of women meet the criteria for alcohol dependence; 25% of medical-surgical inpatients have serious alcohol problems; 10-46% of ER visits are prompted by alcohol; and 17% of ER patients are harmful drinkers. Alcohol is a factor in: 60-70% of homicides; 40% of suicides; 40-50% of fatal motor vehicle accidents; 60% of fatal burns; 40% of fatal falls; and 50% of trauma cases. In addition to all of this, 15-30% of demented nursing home patients have dementia secondary to alcoholism. This devastating litany of statistics demonstrates the primacy of addiction as a pathophysiologic mechanism of disease in modern America.

Given all of the aforementioned objective data, why would someone “choose” to continue their abuse or dependence on food, alcohol, or drugs? The answer is that they don’t “choose”. They are trapped within a deadly obsession and compulsion, which left untreated, will reliably progress to insanity, incarceration, or death. Those who live with the alcoholic or addict can see that their lives are falling apart, the addict, however, doesn’t see this because his emotional brain is telling him that the continued use of his “drug of no choice” is essential to his survival. At this point, the addict’s cortical brain is largely engaged in rationalizing and justifying his continued use. The approach to the patient at this point will be addressed in a separate article. If you are an addict, or the family member of an addict, do not lose heart. There is hope and help for recovery. The purpose of this author’s practice is to facilitate that recovery.


The Family Disease of Alcoholism and Addiction

The disease of alcoholism and addiction affects the family on several different levels. The addict or alcoholic is affected with a life limiting and potentially life-threatening illness which is guaranteed to rob him of his dignity, material possessions, and personal relationships before it eventually ends in insanity, incarceration, or death. The family of the alcoholic or addict is also affected at a very deep level. Their survival as individuals and as a family is on the line. If one of the parents is afflicted with alcoholism or drug addiction, that parent becomes progressively unable to fulfill their normal roles and responsibilities. Typically, the spouse then steps in to attempt to manage a constantly changing and potentially threatening environment. The stress and fatigue associated with this endeavor is often overwhelming, and it leaves little time to focus on the welfare of the children within the family. The focus of the family becomes the parent’s addiction and the compensatory responses to the addiction, which are necessary to preserve the family as a unit.

Owing to the shame inherent in the disease, the family becomes progressively more isolated and invested in keeping secrets. Unspoken rules evolve which include the following: “don’t talk”, “don’t trust”, and “don’t tell”. The various members of the family become highly invested in manufacturing an appearance for the outside world that does not correlate with their internal reality within the family unit. Because of the imbalance that exists within the family, various members of the family begin to take on roles that are not traditionally their roles. For example, if the husband is the alcoholic, then his wife usually tries to take over responsibility for being the breadwinner along with being in charge of the household. The alcoholic is eventually relegated to the role of “misbehaving child.” In the meantime, the children within the family begin to take on different roles in order to support their mother and her ongoing endeavors to preserve the integrity of the family unit. These roles have been previously described in family systems theory and are briefly discussed here for the purpose of illustration only. Usually, one of the children becomes a “hero child”; he excels in academic or athletic achievements outside the home. Another child, usually the youngest, becomes the” mascot.” The mascot provides comic relief in order to decompress the tensions within the family. Several different roles have been described over time and different individuals within the family can temporarily assume different roles according to the present needs of the family structure. The end result of this compensatory role-playing is the loss of the inherent uniqueness of each individual within the family. Instead of becoming who they were meant to be, the children become caricatures of the roles that they played within the dysfunctional family. The relationship between the husband and wife changes from a mutually supportive marital dyad into an adversarial relationship, which pits the “parent” against the “disobedient child”.

As tension mounts within the family, the pressure to seek a solution to the problem increases. Hopefully, the family will break through the denial that surrounds the disease and acknowledge the primary problem as being that of alcoholism or drug addiction. It is usually at this point that members within the family begin to look outside the family for possible solutions. Fortunately, there is abundant help available to the members of the alcoholic family. There is help, hope, and the prospect of a life filled with joy, happiness, and freedom. The sources of help are numerous and include: Al-Anon, a-12 step program for friends and families of alcoholics and addicts; individual counseling; and marital and family counseling. Since Al-Anon is free and readily available to everyone, it will be the focus of the following remarks. Al-Anon is a 12 step program based on the 12 steps of Alcoholics Anonymous, which little by little, one day at a time, can help people to lead happy and fulfilling lives whether the alcoholic is still drinking or not.

One of the key principles of Al-Anon is the four C’s: “I didn’t cause it, I can’t cure it, I can’t control it, and I don’t need to contribute to it”. This simple recognition of reality results in a great deal of relief for those who are burdened with the idea that they are somehow responsible for the alcoholic’s drinking. Another benefit of Al-Anon, is that it teaches healthy detachment from the behavior and the dysfunction promulgated by the alcoholic or addict. Detachment is defined as the ability to love someone enough to allow them to learn from the consequences of their actions. In other words, the practice of detachment involves giving up the role of enabler or facilitator and allowing the alcoholic or addict to suffer the natural consequences that arise from their behavior. Of course, these ideas are radical departures from the status quo, and it takes some time and practice in order to implement them. Nevertheless, consistent application of the principles of Al-Anon, combined with regular Al-Anon meeting attendance can result in increased serenity and peace of mind. This author would highly recommend that anyone involved in a relationship with an active alcoholic or addict seek out Al-Anon and begin attending meetings. It is suggested that people who are new to Al-Anon, attend at least six meetings in different locations before they decide whether or not it is for them.

The purpose of the aforementioned discussion has been to enlighten the reader with respect to the common manifestations of the family disease of alcoholism. It has also been the intent of this author to instill a degree of hope and insight that did not previously exist. The practice of the principles of Al-Anon is akin to a game of skill– one gets better through repetition of the fundamentals. Al-Anon is free, and the practice of its principles can lead you to a freedom and a peace of mind, which was previously thought impossible.

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